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Trying to reduce red tape for traveling nurses


For Kaiser Health News

Lauren Bond, a traveling nurse, has held licenses in five states and Washington, D.C. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.

“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.

The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.

About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.

Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.

Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.

Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho and Arizona.

California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon and Nevada are among the other states that do not accept the multistate license.

Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.

“The nurse shortage tends to wax and wane regionally, so being able to move nurses where the needs are is really, really important,” said Marcia Faller, chief clinical officer at AMN Healthcare, a San Diego-based medical staffing company that employs Bond. The multistate license “really helps with that mobility … to deliver care to patients across state lines.”

Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians and physical therapists.

In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest health care facility might be in Montana, she said.

Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.

Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.

Opponents of the compact argue that states have different standards, course requirements and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.

“The ability to control the standards of training and quality are of some concern to us,” said Linda McDonald, president of United Nurses and Allied Professionals union in Rhode Island, which participated in the original NLC but hasn’t signed on to the new one. “We want them trained in Rhode Island. We want them licensed in Rhode Island.”

Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.

Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.

Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.

Lauren Bond, a traveling nurse who has a temporary position at UCLA Medical Center, Santa Monica, has held licenses in five states and the District of Columbia. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.

Bond, the traveling nurse, said additional courses don’t make her more qualified to do her job. “Across the board, wherever you go to nursing school, everybody comes out with a similar experience,” said Bond, who works at UCLA Medical Center in Santa Monica. “Then most of the training you are going to do is on the job.”

Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.

She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.

“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”

Desperately seeking nurses

Reuters has taken a long look at how hospitals are urgently trying to recruit and retain nurses in a time of a serious national nurse shortage, especially in poor rural regions. To read the piece, please hit this link.

Nurses’ and execs’ salaries fall, physicians’ rise


A new report from Health eCareers shows — not surprisingly! — that hospital executives, physicians, nurse practitioners and physician assistants are easily the highest paid in the sector. While the pay of executives has fallen, that of physicians, NPs and PA rose in the last 12 months.

But the pay of nurses, who are asked to shoulder much of the toughest work in healthcare, fell 3.1 percent. That may lead to more campaigns by unions to organize nurses.

To read the report, please hit this link.


VA wants to expand role of advanced nurses


The Department of Veterans Affairs (VA) has formally proposed to let its advanced practice registered nurses (APRNs) work independently without physician supervision in its  healthcare network, the largest in the nation.

The VA said that expanding the APRN scope of practice in such a way would increase veterans’ access to care and shorten their notoriously long wait times for appointments.

Not surprisingly, the American Medical Association opposes the plan because it runs counter to physician-led, team-based care, which it called the best approach to improving quality.  Many physicians also worry that such change could reduce the influence and income of physicians.

Read more here.


Addressing the “public-health crisis” of nurse burnout


Burnout of overworked nurses is being called a “public health crisis”. According to this Hospitals & Health Networks piece hospitals are addressing the problem in such ways as restructuring hospital leaderships and quiet “renewal rooms” where nurses can take breaks.

Some say that nurse burnout can be caused by the ‘moral distress’ of having to make difficult care decisions. So some hospitals use nursing simulations to practice how to make nurses’ ethical concerns heard,  according to NPR.

Nurses urged to get more active in policymaking


Citing the effects of the Affordable Care Act and nurses winning a wider scope of practice in many states,  the author of an article in Minority Nurse says nurses ought to become more active  in healthcare policy as they gain more authority in hospitals.

Janice Phillips, Ph.D., R.N., noted that conducting research among underserved populations on breast-cancer disparities led her to lobbying and public-policy advocacy to reduce these disparities.

Becker’s Hospital Review summarized her suggestions:

  • “Take health-policy courses during their nurse training.
  • Attend in-person and virtual lobby days.
  • “Analyze publications and presentations for policy implications.
  • “Read policy journals.
  • “Share personal policy-related experiences.
  • “Factor policy components into day-to-day clinical work, such as student interviews with legislators.
  • “Identify policy implications in everyday practice.”



Berwick’s 9 steps to a new ‘moral era’ in medicine


Donald Berwick, M.D.,  former head of the Centers for Medicare & Medicaid Services and now a senior fellow with the Institute of Healthcare Improvement, got a lot of attention with his recent remarks about the wide gap between what health care is and what it could and should be.

He identified two modern eras in modern medicine:  Science, discovery and the trusted doctor captaining the care team defined the first era. The  current, and in some ways, psychologically harsher era can be defined by accountability, measurement, control and punishment.  Dr. Berwick believes that we’re overdo for a third era that puts together the best of  Eras 1 and 2.

Dr. Berwick offers healthcare leaders nine steps to begin to move into what he calls “the moral era” of medicine:

  1. “Stop excessive measurement: I don’t mean that we should stop measuring. Indeed, I celebrate transparency in every form. How else can you learn? But we need to tame measurement. It has gone crazy. Far from showing us our way, these searchlights training on us, they blind us. We can’t find  {a certain patient in need} in that glare. I vote for a 50 percent reduction in all metrics currently being used.
  2. “Abandon complex incentives: We need a moratorium, I think, on complex incentive programs for individual health care workers, especially for doctors, nurses and therapists. If a program is too complicated to understand, too complicated to act upon by getting better, then it isn’t an incentive program. It’s a confusion program. It’s a full-employment program for consultants.
  3. “Decrease focus on finance: This could be impossible. I feel naïve, almost, suggesting it, but for just a while, wouldn’t it be great if we could step off the treadmill of revenue maximizing? … If leaders really did care about profit, they would concentrate unremittingly on meeting the needs of people who came to them for help, but they aren’t. We aren’t.
  4. “Avoid professional prerogative at the expense of the whole: From Era 1, we clinicians, doctors, nurses, we inherited the privilege. It’s still there. We can still use it. It’s the trump card of prerogative over needs, over the interests of others. ‘It’s my operating room time.’ ‘I give the orders.’ ‘Only a doctor can.’ ‘Only a nurse can.’ These are habits and beliefs that die very hard, but they’re not needed. They’re in our way.
  5. “Recommit to improvement science: For improvement methods to work, you have to use them, and most of us are not. I’m trying to be polite, but I am stunned by the number of organizations I visit today in which no one has studied [W. Edwards] Deming’s work, no one recognizes a process-control chart, no one has mastered the power of testing PDSA (plan-do-study-act), Nathaniel’s Method or the route to the top. You can see the proof of concept. This is beyond theory now.
  6. “Embrace transparency: The right rule is really clear to me. Anything we know about our work, anything, anything we know about our work, the people and communities we serve can know too, without delay, without cost or smoke screens. What we know, they know, period.
  7. “Protect civility: With the self-satisfaction courted by Era 1, with the accusatory posture that’s at the heart of Era 2, civility and, therefore, possibility have been in much too short of supply. I don’t lack a sense of humor, although I may sound like it right now, but in my opinion, jokes about herding cats or green eyeshades or soulless bureaucrats or the surgical personality, or the demanding patient — these are not funny.
  8. “Listen. Really listen: These terms — co-production, patient-centered care, what matters to you — they’re encoding a new balance of power: the authentic transfer of control over people’s lives to the people themselves. That includes, and I have to say this, above all, it has to include the voices of the poor, the disadvantaged, the excluded. They need our mission most.
  9. “Reject greed: For whatever reason, we have slipped into a tolerance of greed in our own backyard and it has got to stop … We cannot ask for trust if we tolerate greed. The public is too smart.”

Hospitals working to reduce injuries to nurses


After a tradition of virtually ignoring the problem, U.S. hospitals are making a major effort to reduce nurses’ injuries from the relentless lifting and other work that many must do daily and that forces many of them to retire early.

It’s all about the ‘care teams’



“{Florence} Nightingale receiving the Wounded at Scutari,” by Jerry Barrett

An article in Nurses Count says:

“{W}hen the brand slips, the entire healthcare enterprise starts to unwind and spiral. It’s not pretty. As one CEO said ‘if the care teams stop favoring my hospitals and clinics, and move their procedures and patients away to competitors, as a CEO, I’m cooked.”’

“CEOs do stay awake at night worrying about clinical care and containing unnecessary expenses and reducing variability in the way care is delivered.  In many ways those objective measures of operational performance are ‘easier’ to box, than the ‘unstructured’ perceptions of service quality of patients.  It can be very frustrating.”

“But it’s intertwined by that X-Factor that joins the clinical quality stats with the patient perception of quality measures.  That X-factor is the care team.”

“What drives the quality that is underlying this brand warfare?  It’s our X-Factor— great care teams.”

“For quality of care (a major determinant of healthcare reimbursements), the highest influencing factor according to the study is nursing care, followed by staff responsiveness. The impact of the admissions process, physician care, and the treatment room experience was less than 20%. Message: If you are losing sleep over reimbursements take better care of your nursing team and staff.”

“Top leaders focus on this X-Factor of the care teams because it drives all of these operational statistics and patient quality perception measures. ”


Partners invading urgent-care-clinic business



Prestigious Partners HealthCare,  whose flagship is the Massachusetts General Hospital, will  open as many as a dozen urgent-care clinics over the next three years, in Massachusetts, in a move that helps highlight the more general moves in U.S, healthcare from inpatient to outpatient services and from the use of very expensive physicians to cheaper nurses, nurse practitioners and physician assistants.

It also poses a threat to nearby, Rhode Island-based CVS, whose drugstores are rapidly adding urgent-care centers. The prestige of Partners’  famous hospitals may take some business away from CVS’s urgent-care centers, which it calls MinuteClinics. It may also lighten the load a bit in some area hospitals’ emergency rooms.

Partners is late to urgent care in Massachusetts. Steward Health Care System, Beth Israel Deaconess Medical Center, Lahey Health, and others are already in the business, either directly or with partners, The Boston Globe reports.

But, The Globe reports, “Partners has advantages in its size and reputation. It is the parent of 10 hospitals, including Massachusetts General and Brigham and Women’s, and has 6,000 doctors, the largest network in the state. It also is planning more urgent care locations than most of its competitors.”

“This is more than a pilot for us,” said Dr. Gregg S. Meyer, chief clinical officer of Partners, told The Globe.  “These are meant to be extensions of availability and convenience for patients. We know we are not always as available as possible for our patients.”







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